Dr. Robert Benzo: Changing Outcomes in COPD through Motivational Interviewing

Thank you very much for this opportunity to share what I do. Let me start by introducing myself. My name is Roberto Benzo; I am a clinician, pulmonologist, and behavioral researcher at Mayo Clinic. I direct the Mindful Breathing Laboratory which is directed toward patient-oriented research to improve the quality of life and outcomes in chronic disease.

We hear quite a bit about motivational interviewing these days. What are the basic components of the approach?

Motivational interviewing (MI) is a guiding style to engage people, through which they clarify their strengths and aspirations and, importantly, evoke their motivations for doing what is important for them. MI has been shown to promote behavioral change in a wide variety of health care settings.

Training in MI can follow three steps:

First, practicing a guiding rather than directing style; there is no recipe. We do not tell people what to do or give advice as those approaches are unrewarding and ineffective. MI has outperformed traditional “advice giving” in almost 80 percent of studies. As MI’s wise developers said, “it is not a way of tricking people into doing something we want them to do.”

Second, developing strategies to elicit what is important to patients. Motivation comes from the energy that springs out of trying to do what is important to us. It is not something that we provide; it is something that we extricate from inside a person’s heart and will. MI is emphasizing alternatives and choice. It is attending to a patient’s values as the source of motivation that will give them meaning. That is the biggest question.

Third, we refine our listening skills (simple but tough). Listening is something that is completely underrated and likely the most important part of this process.

In MI-based health coaching, we discuss the change not only of the big items in COPD such as smoking, inhalers, lack of exercise, oxygen or devices. We just talk about what is important to people. And that is where people start to find the root that energizes them to change – which is finding meaning.

Key provider concepts:

Attending to the patient’s values and what provides them meaning. When people find a meaning in their life and they know the “why” (to live), they can tolerate any “how.”

People with COPD are usually frustrated, sad or fearful that they cannot have the life that they used to have, one that is different from their current life. But many times they forget to focus on what is still providing meaning in their life. In MI-based health coaching, we try to get to the core of things that are important to them – have meaning for them – and then find ways for them to work on how to live their lives.

Self-management comes from the will of living the life they have (not regretting it). This is our guide: from finding meaning comes their willingness to live this life, they find their self-efficacy and the way to deal with things such as using medication or devices or going to pulmonary rehabilitation.

Honoring their process and experience. We try to find patients’ own language about what to change, what to do differently, and honor their process. What they do is not more important than how they do it (the process is far more important that the destination). MI-based health coaching is a process that happens with the patient, not something that we do to a patient. The fact that MI is not done with a fixed recipe or content does not mean it is easier to master. It is a lot of work and takes time, but as it is something that a provider is accomplishing and doing day after day, he or she gets better at it.

The evoking process usually involves the patient bringing forward past experience, such as, “what did you do when you were able to deal with, for instance, a COPD exacerbation?” Alternatively, “what is it that you realize you could have done differently that worked before to deal with emotions or breathlessness?” We have people discuss and express what happened before or what they already know, because people with COPD are experts in COPD – much more than many of us doctors, nurses, respiratory therapists, or other providers. This approach gives them meaning, puts them in the drivers’ seat in an open and non cohersive way.

Guiding through listening. We use open questions instead of closed, so we create a different way of thinking about the situation or the problem in front of them; that is the essence of the learning process. Research has shown that the better we do with listening the better the quality of this guiding process, and the better the outcomes. MI research (1) clearly shows that this guiding style improves interpersonal relationships as well as the patient-provider relationship.

Taking the time to master MI. As mentioned, learning MI takes work – time, dedication, and attention. We know that about a third of people that embrace MI are easy learners. Another third struggle, but make substantial gains; another third improve just a little bit.

It is particularly challenging to master the will to listen, which, while it seems easy, is not. Given the noise we often have in our minds when with others, we do not notice what is important for them – a true collaboration then does not exist, because we do not really align to people’s values or what they really want to talk about. And that change talk usually predicts the outcome. If we pick that up, this begins a path for people to start working on themselves and what is important for them.

Accepting all outcomes. A key concept in MI – and a difficult one for us providers to understand – is being flexible with what happens during the process. We give up control on the results: that is key for making patient true drives of their condition. The ingrained thought that “we change people” is sometime the biggest barrier to actually learning this guiding style that is about listening and focusing on the evocation of people.

Our patients will make the decisions they want to. We clinicians need to be ready and willing to accept that patients may not want to change, may want to change using methods that we do not like, or may fail. This is sometimes difficult to accept.

Demonstrating compassion. Finally, compassion is critical to MI. This has recently been added as part of its core in the latest book from MI’s developers, and it has to do with the sincere and honest will of decreasing suffering. This is something very profound that needs to be cultivated, the ability to empty ourselves of what we want to accomplish and really find out what actually is important to people, then to honor that, and to be there as a silent presence for their suffering.

Why did you decide to examine motivational interviewing-based coaching in some of your latest research?

I come from the pulmonary rehabilitation (PR) field. I realized at some point in my career that while we accomplished a lot in improving people’s quality of life (QOL), exercise capacity, and many other health-related outcomes in the short term, we did not advance much on creating habits and behavioral change.

To maintain the benefit of PR, you need behavior change. At that point, I switched to study behaviors (e.g., focusing on physical activity rather than exercise capacity). I started to explore where I can actually help to make lasting changes, things that people would continue doing. That is where I found MI as a scaffold, a framework that can be used for that change.

I learned that change happens when we dilligently work on the things are important to us, not to the doctor or others, but important to us. Once a person starts repetitively doing things toward a doable goal that is important to him or her , they create a new pathway in the brain: habits (what neuroscientists call neuroplasticity).

I amazingly found that no matter our age, if we develop awareness and meaning, we build new ways of approaching life – that is already ingrained in us – and our brain changes when we develop these habits.

In a sense, I wanted to learn a way to focus on what is important and be more content in my life and translate that to my patients. I strongly believe that health is about balance, not the absence of disease or the lack of chronic conditions,. It is about how we juggle everything that is happening to us; it is about our relationships and our situation in life, including COPD. I believe too that when people do MI-based health coaching, they not only listen to patients, they have to listen to themselves, and that is very transformative. I live this philosophy myself: that is not just for “patients”—it is for everybody.

What were the findings of your most recent research?

Briefly, our randomized study tested an intervention that involved MI-based health coaching plus emergency medications (antibiotic and prednisone, to be activated at the start of an exacerbation) and a very brief exercise intervention in COPD patients hospitalized for an exacerbation. The health coaching was weekly for three months and monthly after that for a year.

We found that the intervention was effective to decrease hospitalization at 1, 3, 6 and 9 months post-discharge and significantly improved the quality of life after hospital discharge at 6 and 12 months after the intervention started. It is huge. The benefit of reducing hospitalization came from the MI-based health coaching and did not relate to the use of the emergency medications (antibiotic and prednisone); nor to higher physical activity. However, I think that this emergency intervention to be used during the onset of an exacerbation is a very important tool, perhaps necessary but not sufficient to make a difference. It is the behavior associated with the use of the emergency prescriptions that may make the difference: the self-efficacy, the self-confidence of people to do it at the moment, that is necessary.

What would you say your results means to patients and clinicians in the field?

In perspective, our health coaching study(1) is the first randomized evidence of a successful intervention applied at discharge in patients hospitalized for COPD exacerbation that was shown to decrease readmissions. Importantly, the exercise piece did not lead to improvement in physical activity. Again, so we postulate that health coaching may carry the most of the beneficial effect in hospitalizations and quality of life. We also saw decreases in the amount of severe or significant exacerbations as emergency department visits.

There was also sustained improvement in emotional quality of Life (QOL). So far, PR has been the only thing that unquestionably shows improvement in emotional QOL (and physical QOL in the short term); however, uptake is an issue as many people cannot get to it. I believe that health coaching is a tool that improves emotions in COPD and is also synergistic or complementary to the great work that we do in PR, either at home PR or at a center.

Also of note is the impact this has on the provider. We are currently doing a quality study on health coaches, and the process is truly transformative to these individuals. It is not only important for patients, the main focus of our work, but for providers.

In closing, health coaching is possible and there are more and more opportunities to train yourself on these skills. The core of coaching is to create dialogue, in the space of inquiry between the patient and clinician, about what is important to the patient and what will help them sustain the life that is here and now.

MI-based health coaching is another tool complementary to PR for patients to live their current lives better and to avoid hospitalization and ER visits. It is not a panacea; it is, however, another tool in the toolbox. It has everything to do with honoring life, honoring dialogue, listening to patients and listening to ourselves – and promoting real connections that heal.

6 Comments

Excellent article and very insightful. As a case manager i appreciate the confirmation that this tool is valuable in effecting outcomes.I also strongly feel that MI is the key to empathy, really" walking in their shoes"- it gives a mirror into their world. If we are to collaborate with patients and their loved ones, we need to know what it feels like to be them, not just sympathize. Understanding what really matters to them. Thank you Dr. BenzoReply

I am very fortunate that Dr. Benzo is my pulmonary physician. His work in Mindful Awareness also serves to provide more positive outcomes. I thoroughly enjoyed reading the interview!Thanks for sharing!Reply

In the Primary Care Resource Center (PCRC) here at Mon Valley Hospital, Motivational Interviewing (MI) was introduced to us by our grant funder, the Pittsburgh Regional Health Initiative (PRHI), from our beginning in 2012. . .and most of the clinical team resisted. The Team are all seasoned clinicians who were very occupied with creating the program and believed that they had spoken with hundreds of patients for years and did not need to learn how to talk with patients. We were wrong. After our initial series of trainings, we realized the immense value of MI in coming to a truly patient-centered treatment plan, with patient-centered goals. While the concepts of MI appear simple and almost intuitive, adopting the principles and utilizing them is complex and ongoing. In the PCRC, we attempt to design tools and processes for the Team that support MI use; have kept up with multiple trainings and find it of major value to have a Team that all has the same perspective, where we try to support and coach each other in using the 'spirit of MI' as we continually try to upgrade our MI skills. It is a major shift in focus - we now do not use the term 'non-compliant'. . .patients are making choices other than the ones being presented to them. . .we try to use MI to determine and guide the reasons for those choices. We really recommend this focus. Thank you for the article.Reply

Amazing article, amazing practice. And how far away we fell from common sense and really hearing. There are always messages between spoken words and we have to be careful not to fill them in for people. Thank you for posting and thank you Dr. BenzoReply